Antisocial personality disorder is a condition in which people show a pervasive disregard for the law and the rights of others. People with antisocial personality disorder may tend to lie or steal and often fail to fulfill job or parenting responsibilities. The terms "sociopath" and "psychopath" are sometimes used to describe a person with antisocial personality disorder. Some scholars, such as Robert Hare, still distinguish psychopathy from mere antisocial behavior.

Antisocial personality disorder is the most reliably diagnosed condition among the personality disorders, yet treatment efforts are notoriously difficult. Therapeutic hope has not vanished, however, and one study indicated that almost two-thirds of psychiatrists think that "psychopathic disorder" is sometimes a treatable condition. A similar finding was reported nearly 40 years ago. Diagnostic refinement is critical before any treatment efforts are undertaken, especially the determination of the degree of psychopathy in the patient with antisocial personality disorder.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) by the American Psychiatric Association (APA) (1994), ASPD is characterized by a pervasive disregard for, and violation of, other people's rights.

The concept of such a personality type is not new. For example, Theophrastus, a student of the ancient Greek philosopher Aristotle, described a personality type that he termed the "unscrupulous man" and which included behaviors that are significant elements of the current concept of ASPD (Millon et al. 1998).

During the past century, researchers and clinicians have used numerous terms to describe ASPD, including "moral insanity," "psychopathy," and "sociopathy." Likewise, the symptoms considered to be the key elements of psychopathy or an antisocial personality have evolved from a focus on the lack of emotional attachment in relationships with others (Cleckley 1964) to a greater focus on external behaviors, especially aggressive and impulsive behaviors (APA 1994).

The current criteria for ASPD, as described in DSM-IV, include a behavioral pattern that begins before age 15 and comprises at least three of the following behaviors:

Alternative names

Symptoms & Signs

The classic person with an antisocial personality is indifferent to the needs of others and may manipulate through deceit or intimidation. He or she shows a blatant disregard for what is right and wrong, may have trouble holding down a job, and often fails to pay debts or fulfill parenting or work responsibilities. They are usually loners.

The diagnostic criteria for antisocial personality disorder are set forth in table above. DSM-IV states that this disorder is characterized by "a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood." The antisocial features are reflected in poor job performance, academic failure, participation in a wide variety of illegal activities, recklessness, and impulsive behavior.

The patient with antisocial personality disorder also experiences a feeling of subjective dysphoria, characterized by tension, depression, inability to tolerate boredom, and a feeling of being victimized. There is also a diminished capacity for intimacy.

A substantial body of research has shown that only a minority of patients with antisocial personality disorder have severe psychopathy, and this latter group has a significantly poorer treatment prognosis than do patients with nonpsychopathic antisocial personality disorder.

They appear to be incapable of any true emotions, from love to shame to guilt. They are quick to anger, but just as quick to let it go, without holding grudges. No matter what emotion they state they have, it has no bearing on their future actions or attitudes.

Disregard for the feelings of others

Impulsive and irresponsible decision-making

Lack of remorse for harm done to others

Lying, stealing, other criminal behaviors

Disregard for the safety of self and others

Common countertransference reactions to the patient with antisocial personality disorder

Therapeutic nihilism (condemnation)

Illusory treatment alliance

Fear of assault or harm (sadistic control)

Denial and deception (disbelief)

Helplessness and guilt

Devaluation and loss of professional identity

Hatred and the wish to destroy

Assumption of psychological complexity

Natural History & Prognosis

Antisocial personality disorder tends to remit with time. After 21 years of age, the remission rate is about 2% of all patients each year. As destructive social behavior diminishes, patients tend to develop hypochondriacal and depressive disorders.

Epidemiology

Onset of antisocial personality disorder is before age 15, frequently around puberty in girls and quite early in childhood for boys. The disorder is more prevalent in men, with incidence being about 3% for men and 1% for women. Prevalence is increased in lower socioeconomic groups. Family histories are often positive for antisocial personality disorder, with increased incidence in the fathers of both male and female patients with this disorder. Evidence suggests that this familial occurrence results from both genetic and environmental causes; the relative contribution of each factor is unknown. Antisocial personality disorder may be diagnosed in as many as 75% of prison inmates.

Etiology & Pathogenesis

The exact causes of antisocial personality disorder are unknown, but experts believe that both hereditary factors and environmental circumstances influence development of the condition.

A. Genetic and Biological Factors: Robins (1966) found an increased incidence of sociopathic characteristics and alcoholism in the fathers of individuals with antisocial personality disorder. Within the families of these individuals, male relatives have increased rates of antisocial personality disorder and substance abuse disorders, whereas female relatives have increased rates of somatization disorder. Adoption studies support the role of both genetic and environmental contributions to the development of the disorder. In a retrospective study of this disorder, Raine et al (1990) reported that indices of psychophysiological underarousal at age 15 were predictive of criminality at age 24 years. Criminals had significantly lower heart rates and skin conductance activity and more slow-frequency electroencephalographic activity than noncriminals.

B. Psychological Factors: Bowlby (1944) correlated antisocial personality disorder with maternal deprivation in the child's first 5 years of life. Glueck and Glueck (1968) reported that the mothers of children who developed this personality disorder show a lack of consistent discipline, a lack of affection, and an increased incidence of alcoholism and impulsiveness. These qualities contribute to failure to create a cohesive home environment with consistent structure and behavioral boundaries. In the prospective study, children found to be at risk by age 6 frequently showed features of antisocial personality at 18 years.

Differential Diagnosis

The diagnosis of Antisocial Personality Disorder is not given to individuals under age 18 years and is given only if there is a history of some symptoms of Conduct Disorder before age 15 years. For individuals over age 18 years, a diagnosis of Conduct Disorder is given only if the criteria for Antisocial Personality Disorder are not met.

When antisocial behavior in an adult is associated with a Substance-Related Disorder, the diagnosis of Antisocial Personality Disorder is not made unless the signs of Antisocial Personality Disorder were also present in childhood and have continued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a Substance-Related Disorder and Antisocial Personality Disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the Substance-Related Disorder (e.g., illegal selling of drugs or thefts to obtain money for drugs). Antisocial behavior that occurs exclusively during the course of Schizophrenia or a Manic Episode should not be diagnosed as Antisocial Personality Disorder.

Prevalence

The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8% of males and 1.2% of females showed evidence of a lifetime risk for the disorder. Prevalence estimates within clinical settings have varied from 3% to 30%, depending on the predominant characteristics of the populations being sampled. Perhaps not surprisingly, the prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders) (Hare 1983). Similarly, the prevalence of ASPD is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between ASPD and AOD abuse and dependence.

Complications

People with antisocial personality disorder are at an increased risk of:

Dying from a physical trauma, such as an accident

Drug and alcohol abuse

Suicide

Homicide

Other mental disorders such as depression, bipolar disorder and anxiety

Treatment

The most important goals of treating antisocial behavior are to measure and describe the individual child's or adolescent's actual problem behaviors and to effectively teach him or her the positive behaviors that should be adopted instead. In severe cases, medication will be administered to control behavior, but it should not be used as a substitute for therapy.

In a review of the effectiveness of treatments for antisocial personality disorder Garrido et al (1995) concluded that treatment is more effective with those subjects who are not currently abusing drugs, who have less serious histories of criminality, and who are treated in an institutional setting such as an inpatient unit or a prison rather than in an outpatient setting. As an example Dolan (1998) describes a therapeutic community program for antisocial patients and those with other violent personality disorders that is successful in reducing not only impulsive behaviors but also physical health problems, rates of incarceration for criminal offenses, and core features of personality disorder.

Effective psychotherapy treatment for this disorder is limited. It is likely, though, that intensive, psychoanalytic approaches are inappropriate for this population. Approaches the reinforce appropriate behaviors and attempting to make connections between the person's actions and their feelings may be more beneficial. Emotions are usually a key aspect of treatment of this disorder. Patients often have had little or no significant emotionally-rewarding relationships in their lives. The therapeutic relationship, therefore, can be one of the first ones. This can be very scary for the client, initially, and it may become intolerable. A close therapeutic relationship can only occur when a good and solid rapport has been established with the client and he or she can trust the therapist implicitly.

Antisocial Personality Disorder in Medical Practice

The relationship between a physician and a patient with antisocial personality disorder is characterized by mutual feelings of suspicion and, at times, hostility. The antisocial person's mistrust of the physician stems from unwarranted generalizations about physicians that are based in part on early abusive experiences at the hands of parental caretakers, particularly during the formative periods of childhood and adolescence. The physician's mistrust of the antisocial patient may well be grounded in unpleasant personal experience. Persons with antisocial personality disorder may feign physical symptoms to obtain narcotic analgesics for substance abuse, may attempt to defraud third-party health care payment sources by seeking reimbursement for services not rendered, or may be delinquent in payment for services they have actually received. Unfortunately, individuals with antisocial personalities are at least as vulnerable to physical illness as any other type of patient and are in fact at higher risk for illnesses associated with substance abuse and stress because of their chronic unstable interpersonal and occupational adjustments. The physician is therefore challenged to find a way to create an effective therapeutic alliance. A firm, no-nonsense approach that is not punitive but conveys a streetwise awareness of the patient's potential for manipulation will encourage respect without aggravating the patient's hostility against authority.

Illustrative Case

A 25-year-old man presented for an initial visit to a local general practitioner and complained of recurrent backache. He said that he had tried many analgesics in the past and found that they either were ineffective or caused intolerable side effects, with the exception of high doses of codeine. Physical examination revealed significant disease of the lumbosacral spine secondary to a congenital defect in the alignment of the vertebrae.

Alerted by the patient's specific request for a potentially addictive narcotic that also had high resale value in the illicit drug market, the physician inquired further into the patient's work and occupational history. A typical unstable pattern of impulsive and manipulative interpersonal relations was identified, including an irregular work history and other features characteristic of antisocial personality disorder. A respectful but appropriately tough tone of inquiry into the patient's previous use of analgesics revealed a history of morphine addiction following lower back surgery. Denial of the patient's request for codeine led to an angry outburst, with the patient declining alternative treatment. Several months later, however, the patient reappeared with legitimate complaints of upper respiratory tract infection. He told the physician, "I came back to see you again because I figure you're nobody's fool, but you're not going to lecture me about how I should live my life either."

A 21-year-old divorced independent trucker was referred for pretrial psychiatric evaluation after being charged with interstate transportation of stolen property. He had a history of repeated criminal offenses, prison terms, and psychiatric disturbance during childhood and adolescence. He had been apprehended 4 weeks earlier when a random road inspection revealed stolen automobile parts hidden among cartons of groceries.

About 8 months before his latest arrest, the patient had suddenly abandoned his wife when he learned from an acquaintance that she sometimes flirted with customers at the sandwich shop where she worked.

The patient was the second in a family of four boys. His alcoholic father was episodically violent toward him when drunk, and his mother was absent long hours while she worked to support the family.

During childhood, the patient had been evaluated and briefly treated in a community mental health center after he had been caught setting fire to an abandoned warehouse. During adolescence, he had received counseling from a school psychologist because of a consistent pattern of antisocial behavior, including car theft, joyriding, drunk driving, driving with a suspended license, truancy, and stealing money from his mother. While he was growing up, he had no close friendships, although he was a peripheral member of a hot-rod gang. Though sexually active from a young age and proud of his sexual prowess, he was mistrustful of women and became easily bored with the same partner.

In the interview, the patient appeared nonchalant and composed, with an apparent equanimity that was incongruent with the seriousness of his situation. He made eye contact with the interviewer but appeared to be looking through the interviewer rather than at him. There was an unspoken but clearly communicated disregard for the interviewer's authority. There were no major disturbances in thought, perception, or mood, with the exception of a lack of remorse or anxiety when he was confronted with his lifelong pattern of destructive behavior and the seriousness of the charges presently lodged against him.

Antisocial Personality Disorder, Alcohol, and Aggression

Epidemiologic studies and laboratory research consistently link alcohol use with aggression. Not all people, however, exhibit increased aggression under the influence of alcohol. Recent research suggests that people with antisocial personality disorder (ASPD) may be more prone to alcohol- related aggression than people without ASPD. As a group, people with ASPD have higher rates of alcohol dependence and more alcohol-related problems than people without ASPD. Likewise, in laboratory studies, people with ASPD show greater increases in aggressive behavior after consuming alcohol than people without ASPD. The association between ASPD and alcohol-related aggression may result from biological factors, such as ASPD-related impairments in the functions of certain brain chemicals (e.g., serotonin) or in the activities of higher reasoning, or "executive," brain regions. Alternatively, the association between ASPD and alcohol-related aggression may stem from some as yet undetermined factor(s) that increase the risk for aggression in general.

Prognosis

Prognosis is not very good because of two contributing factors. First, because the disorder is characterized by a failure to conform to society's norms, people with this disorder are often incarcerated because of criminal behavior. Secondly, a lack of insight into the disorder is very common. People with antisocial personality disorder typically see the world as having the problems, not him or herself, and therefore rarely seek treatment. If progress is made, it is typically over an extended period of time.

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